Inspection on 30/01/06 for Holmdale Terrace

This inspection was carried out on 30th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holmdale Terrace 03/01/08

Holmdale Terrace 23/01/07

Holmdale Terrace 30/11/04

Holmdale Terrace 05/08/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Holmdale Terrace 4 Holmdale Terrace Stamford Hill London N15 6PP Lead Inspector Wendy Heal Unannounced Inspection 30th January 2006 09:30 Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Holmdale Terrace Address 4 Holmdale Terrace Stamford Hill London N15 6PP 020 8809 3638 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Tulip Mental Health Group Alberta Yondah Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6), Physical disability (2) of places Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Limited to 6 adults of either gender who have a mental disorder (MD) 2 of whom may also have a physical disability (PD) 27th July 2005 Date of last inspection Brief Description of the Service: Holmdale Terrace is owned by Circle 33 Housing Association and operated as a residential home by Tulip Mental Health Group. The home was registered in 1995 and provides care and accommodation for six people with mental health problems. The home is a terraced property located near a railway line in a quiet street in the Stamford Hill area, with shops near by. There are four single rooms and two semi-independent studio flats, which include a lounge/kitchenette and bedroom. There are two bathrooms in the house; the downstairs bathroom has been adapted to provide a walk in shower. There is a communal lounge on the first floor. The kitchen is bright and has a large wooden dining room table and chairs in the middle. Staffing at the home consists of a project manager, deputy project manager and two project workers. There are three members of staff on the early turn shift and one member of staff on the late turn shift between 5pm and 9.30pm. The home now provides an additional member of staff two evenings per week to support service users to undertake activities in the community. The principle aim of the home is to provide the emotional and practical support necessary to enable service users to exercise a degree of independence and self-determination in their lives. Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took approximately 5 hours. The manager, Alberta yondah assisted the inspector throughout the day. The inspector undertook a tour of the building, spoke with five service users observed the interaction between the service users and the staff. The inspector spoke with the staff member on duty and also observed the staff handover. Further information was obtained by an inspection of the documentation kept in the home, including care plans, and health and safety documentation. At the time of the inspection the manager was also taking part in a regulation 26 visit. The inspector would like to thank the service users present during the inspection, the manager and staff for their openness and participation. What the service does well: What has improved since the last inspection? The manager is undertaking improvements to the staff office in relation to redecoration and replacement of the carpet. Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 6 What they could do better: The information required in relation to service users not reacting to the fire drill must be included in the risk assessment and care plan. A requirement has been made in relation to this. Staff must improve the frequency of recording activities on the necessary documentation. A good practice recommendation has been made in relation to this. The shower flooring must be replaced. A requirement has been made in relation to this. A blind at the window and comfortable seating must be provided in the kitchen area. A requirement has been made in relation to these. The kitchen must be redecorated. A requirement has been made in relation to this. The smoking room must be redecorated and the chairs replaced. A requirement has been made in relation to this. The purpose and function document must be updated. been made in relation to this. A requirement has The London Fire and Emergency Planning Authority must be consulted in relation to what is agreed with regard to action to be taken when service users who do not leave the home when a fire drill is sounded. A requirement has been made in relation to this. The London Fire and Emergency Planning Authority must be consulted in relation to the homes Disaster Recovery Plan. A requirement has been made in relation to this. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5 Prospective service users and their representatives have a range of information to allow them to make an informed choice about living at home. Prospective service users needs are also assessed before they move into the home so that the home can identify the support and resources necessary to address these needs. Service users benefit from having a clear statement of their rights and responsibilities relating to living at the home. EVIDENCE: The inspector looked at the statement of purpose and admissions policy. The purpose and function document needs to be updated. A requirement has been made in relation to this. The inspector noted that the service users guide is well laid out and up to date. There is evidence that service users have the opportunity to visit and to testdrive the home. Service users come to the home for an initial visit with their family and carers. The service user would then return for lunch and meet the other service users living within the home. The service user would then attend for a full day and take part in day-care activities and attend a tenants meeting before carrying out their first overnight weekend stay. Three service user files were inspected. All contained clear assessment information that is being reviewed on a regular basis. The assessment process normally includes a six weeks assessment, which would involve looking at Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 9 areas like daily living skills, budgeting. The service users daily activities would continue and the final meeting would be the discharge meeting. The manager and staff interviewed showed they had a good understanding of the individual service users needs and could talk in detail in relation to their role. Each service user has an individual written contract of terms and conditions that included a notice period that was signed by the individual service user. Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 The service is good at enabling service users to make decisions for themselves about what they want to do, when they want to do it, and to take calculated risks so the service users are helped to be as independent as possible. EVIDENCE: The service users case notes were inspected. The service users care plans were satisfactory. The inspector took part in a discussion with the manager and the identified service user who does not attempt to leave the home when the fire drill or bell test take place but prefers to remain in his bedroom. The Manager must have this information included in his care plan and the attached risk assessment. A requirement has been made in relation to this. The care plans were based on service users individual and changing needs. The inspectors saw evidence that care plans are being reviewed. The inspector saw evidence that appropriate risk assessments are in place and are being reviewed. Tenants meetings to discuss issues relating to the service users take place. A range of topics are discussed Including activities, relationships, current affairs Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 11 such as gay and lesbian marriages and current issues in relation to The Liberal Democratic Party. Service users demonstrated that they could make decisions and choices about their daily lives. On the day of the inspection one service user came to the manager to check her finances and obtain money to complete shopping for the week. This identified service user also informed the manager that she would be going to Wood Green to have lunch. The service users undertake a variety of day-care activities, for example one service users club undertakes activities such as news and views, Internet, lifestyle group, and creative arts. One service user attends a Jewish Day Centre and has access to dial a ride. There is also a music group on Wednesday, which is organised by a member of the current staff team. However the activity reports do not fully reflect the range of activities that the service users are involved in. The staff must improve the frequency of the recording in relation to the activity programme. A good practice recommendation has been made in relation to this. Services user information is handled appropriately. The files are kept in the main office. The inspector observed the level of confidentiality in the home and is satisfied that staff working at Holmdale Terrace keep all information regarding service users secure. Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12; 13,15,16,17, The home supports service users to take part in appropriate activities including those that are community based. The development and support of service users personal relationships is taken seriously by the home, as is their encouragement of service users to enjoy a healthy diet. EVIDENCE: On the day of the inspection, one service user was going to buy her weekly shopping and then have lunch out. The inspector spoke with her and she confirmed she enjoys going to the local shops, Wood Green shopping centre and eating out. One service user spoken with enjoys going to the local ballet. The staff rota indicates additional staffing available in the evenings to allow service users involvement in activities to take place. Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 13 Service users are supported to maintain contact with their family and friends. A number of former service users who now live in their own homes still come back to visit. Service users enjoy varied and balanced meals of their choice. Staff are aware of the service users preferences in relation to their meals and these are clearly identified in the individual care plans. On the day of the inspection the inspector noted that fresh fruit and vegetables were available. The inspector observed from the menu that service users are supported to prepare snacks in the evening and have a hot meal at lunchtime. Service users favourite foods are recorded in their care plan. The service users involvement in the completion of the weekly menu is evidenced in the tenants meetings, which take place each week. There was evidence available that service users had attended both the Chinese and Indian restaurant. Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Service users benefit by the systems in place with regard to the administration of their medication. EVIDENCE: The service users spoken with were very positive in relation to the staff working in the home. The records in relation to the administration of medication, and the storage of medication were found to be in order. Service users files indicated that support was given to access appropriate medical services. The inspector saw evidence of dental appointments, blood tests and contact with their General Practioner. Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Service users can feel that their views are listened to and acted upon and can be confident that they will be protected from abuse and self-harm. EVIDENCE: The record of complaints was inspected and there had been one complaint made since the previous inspection. The complaint had been appropriately recorded. The care coordinator had been contacted along with the director. A meeting had taken place with the staff at Holmedale Terrace and the expectations of both the service user and staff were documented. Some negotiations took place and a complaints response form had been completed. The organisation has its own complaints procedure. The manager has developed some very user friendly forms in relation to service users expressing their views and making the decision as to whether they want to make a formal complaint. This also includes a complaints response form, a dissatisfaction response form and comments form. There is an adult protection procedure, which is in place and meets the requirements of this standard. Guidance regarding whistle blowing is contained in a separate policy and procedure. Staff had undertaken adult protection training and protection of vulnerable adult training. Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28,29,30 Service users benefit from living in a homely setting. Service users will benefit from improvements in the environment. EVIDENCE: The home offers an appropriate domestic type environment. The inspector was invited by three service users to see their bedroom, which were clean and tidy and contained the service uses personal possessions reflecting their personality and preferences and were equipped to meet their individual needs. The inspector was also invited into two of the independence flats within the home. The ground floor shower was inspected. The flooring in the ground floor shower needs to be replaced with a new nonslip replacement. A requirement has been made in relation to this. Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 17 The kitchen was equipped with all the necessary appliances to enable service users to prepare meals and snacks. The kitchen is in need of redecoration. A requirement is made in relation to this. The kitchen would benefit from a blind at the window and some additional comfortable seating to make this area more homely. A requirement has been made in relation to this. Having had a discussion with the manager, the inspector is of the opinion that the smoking room on the top floor of the house needs to be redecorated and some new comfortable chairs obtained. A requirement has been made in relation to this. The office is in need of redecoration and replacement of the current carpet. The manager showed the inspector evidence that she had already planned for this to take place and was in the process of obtaining quotations. A tour of the building showed a good standard of cleanliness within the home. Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,35,36 Service users benefit from clearly set out staff roles and responsibilities, and the knowledge and skills, which staff have developed through ongoing training and support. EVIDENCE: The manager informed the inspector that staff are undertaking their NVQ. The manager is also undertaking her registered managers award. The manager had recently undertaken a Protection of Vulnerable Adults training course. A new member of staff had undertaken First Aid training. This member of staff was also undertaking a one-day Medication-training course. He was waiting for a date to undertake Food hygiene training. An established member of staff was undertaking the four-day First Aid course. Two members of staff had undertaking Manual handling training and Food hygiene training. Staff was observed to have a clear understanding of their roles and responsibilities from the conversation the inspector had with them. Supervision records were inspected and all staff are receiving regular supervision. Regular staff meetings are taking place. The staff rota was inspected and found to be in order. Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 19 The registered manager informed the inspector that she is in the process of recruiting to the vacant staff posts. This includes the deputy managers position. The manager has agreed to inform the inspector in writing when this post has been recruited to. Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 40,42 Planning for the future will underpin the good work that the home does in listening to and acting upon the views of service users, who benefit from living in a home where their health and safety is actively promoted and protected. EVIDENCE: The registered provider must submit a written annual development, business plan for the home to the Commission for Social Care Inspection. Records relating to fire tests and evacuations were up-to-date and carried out regularly. On some occasions service users have been reluctant to leave their rooms during fire drills. Records seen during the inspection show that staff have worked hard in meetings and individual key worker sessions to impress upon service users the importance of fire drills to their safety. The manager has agreed to include these identified risks in the service users care plan and risk assessments. The manager has also agreed to consult with the London Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 21 Fire and Emergency Planning Authority in relation to the agreed action to be taken in this situation. The manager will consult the London Fire and emergency planning authority in relation to The Disaster Recovery Plan. Requirements had been made in relation to these. The homes gas certificate was seen and found to be in order. Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 3 5 3 CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 2 3 LIFESTYLES Standard No Score 11 2 12 3 13 3 14 2 15 2 16 3 17 32 33 34 35 36 3 X X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X 39 40 41 42 43 X X 2 2 X 2 X Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA1 YA9 Regulation 4(1) 13(1)(c) Timescale for action The homes Statement of Purpose 10/04/06 must be updated. The service users who do not 01/03/06 leave their room when the Fire bell is sounded must have this information and the action to be taken included in their Care Plan and risk assessment. The flooring in the downstairs 10/04/06 shower room must be replaced. The kitchen must be 10/05/06 redecorated. A blind should be fitted to the window. Comfortable chairs to be obtained. The smoking room on the top 01/04/06 floor must be decorated. The chairs in this room must be replaced. The London Fire and Emergency 01/06/06 Planning Authority must be consulted in relation to the homes Disaster Recovery Plan. The registered provider must 01/04/06 submit a written annual development/business plan for the home to the Commission for Social Care inspection. Requirement 3. 4. YA27 YA24 23(2)(b) 23(2)(b) 5. YA24 23(2)(d) 6. YA42 23(4)(3) 7. YA39 24(1)(b) Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 40 Good Practice Recommendations Staff should improve the recording of service user leisure activities. Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Holmdale Terrace DS0000010736.V284594.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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